Revision 17-1; Effective March 1, 2017

 

 

 

9100 Initial Service Authorization

Revision 17-1; Effective March 1, 2017

 

These records must be completed to check or create an initial service authorization for the STAR+PLUS Home and Community Based Services (HCBS) program.

  • Authorizing Agent
  • Enrollment
  • Service Plan
  • Service Authorization
  • Level of Service
  • Medical Necessity
  • Diagnosis

 

9110 Authorizing Agent

Revision 17-1; Effective March 1, 2017

 

There will normally be one authorizing agent registered for a STAR+PLUS Home and Community Based Services (HCBS) program applicant.

Initial individual service plans (ISPs) submitted through the Long Term Care (LTC) portal have a system-generated authorizing agent. The LTC portal interfaces with the Service Authorization System (SAS) and records "STAR+PLUS" in the Authorizing Agent Field and records the managed care organization (MCO) service coordinator's name in the Name field.

The LTC portal generates changes to the SAS authorizing agent records for a member with a plan code change during an ISP year for which a current or future ISP is in a "processed/complete" status. In this case, a SAS authorizing agent record is created for the 'child' ISP with a begin date equal to the new plan effective date. The SAS authorizing agent record for the ‘parent’ (transferred) ISP is automatically ended with the prior plan enrollment end date.

The Program Support Unit (PSU) does not register an authorizing agent for electronic ISPs. PSU confirms the authorizing agent registration in SAS, takes a screenshot, and posts the screenshot to HHS Enterprise Administrative Report and Tracking System (HEART).

The PSU or Texas Health and Human Services Commission (HHSC) Enrollment Resolution Services (ERS) staff are registered as the authorizing agent when the initial authorization is authorized.

To register an authorizing agent for a  STAR+PLUS HCBS program applicant whose ISP is posted to TxMedCentral:

  1. Select the Authorizing Agent area in the Case Worker Functional area.
  2. Select Add and a blank Authorizing Agent Details record will appear.
  3. Move to the Type field and select CM – Case Manager from the drop-down menu.
  4. Move to the Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Leave the Send to TMHP field at the default selection N - NO.
  6. Move to the Begin Date field and enter the date the record is being created. Leave the End Date field blank.
  7. Move to the Authorizing Agent field and enter STAR+PLUS.
  8. Leave the Agency field at the default selection 324 - DHS.
  9. Move to the Name field and enter the PSU/ERS staff’s name.
  10. Move to the Phone field and enter the telephone number of the authorizing agent. Enter the area code, phone number and extension.
  11. Move to the Mail Code field and enter the appropriate Managed Care Organization (MCO) Plan Code from the table below. Note: Six service areas include Medicare-Medicaid Plans (MMP).
Service Area MCO Plan Name MCO Plan Code

Bexar

Amerigroup

45

Molina

46

Superior 47
Amerigroup MMP 4F
Molina MMP 4G

Superior MMP

4H

Dallas

 

Molina

9F

Superior Health Plan

9H

Molina MMP 9J
Superior MMP 9K

El Paso

Amerigroup

34

Molina

33

Amerigroup MMP 3G
Molina MMP 3H

Harris

Amerigroup

7P

United Healthcare

7R

Molina

7S

Amerigroup MMP 7Z
United Healthcare MMP 7Q
Molina MMP 7V

Hidalgo

Cigna-HealthSpring

H7

Molina

H6

Superior

H5

Cigna-HealthSpring MMP H8
Molina MMP H9
Superior MMP HA
Jefferson

Amerigroup

8R

United Healthcare

8S

Molina

8T

Lubbock

Amerigroup

5A

Superior 5B
Medicaid Rural Service Area (RSA) Central Texas Superior C4
United Healthcare C5
Medicaid RSA
Northeast Texas
Cigna-HealthSpring N3
United Healthcare N4
Medicaid RSA
West Texas
Amerigroup W5
Superior W6

Nueces

United Healthcare

85

Superior Health Plan

86

Tarrant

Amerigroup

69

Cigna-HealthSpring

6C

Amerigroup MMP 6F
Cigna-Healthspring MMP 6G

Travis

Amerigroup

19

United Healthcare

18

  1. Select the Save button.

 

 

9120 Enrollment

Revision 17-1; Effective March 1, 2017

 

To register enrollment for a STAR+PLUS Home and Community Based Services (HCBS) program applicant:

  1. Select the Enrollment area in the Program and Service Functional area.
  2. Select Add and a blank Enrollment Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Enrolled From field and select the appropriate entry from the drop-down menu.
  5. Move to the Living Arrangement field, and select the appropriate community-based living arrangement from the drop-down menu.
  6. Move to the Begin Date field and enter the date the member is to be enrolled in his MCO, which will always be the first day of a month.
  7. Leave the End Date field blank.
  8. Leave the Termination Code and Waiver Type fields at the defaults.
  9. Select the Save button.

 

 

9130 Service Plan

Revision 17-1; Effective March 1, 2017

 

The Service Plan record is used to register an individual service plan (ISP) for a Home and Community Based Services (HCBS) program plan member. The record includes the annual STAR+PLUS HCBS program ISP cost limit based on the member’s Resource Utilization Group (RUG) value and the total estimated cost of STAR+PLUS HCBS program services taken from the member’s Form H1700-1, Individual Service Plan, for individuals who do not have an electronic ISP.

To register a service plan for a STAR+PLUS HCBS program applicant whose ISP is posted to TxMedCentral:

  1. Select the Service Plan area in the Program and Service Functional area.
  2. Select Add and a blank Service Plan Details record will appear.
  3. Leave the Type field at the default selection AN - ANNUAL PLAN.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Ceiling field and enter the annual STAR+PLUS HCBS program ISP cost ceiling for the RUG value entered on the Level of Service record. For a STAR+PLUS HCBS program member who is ventilator use-dependent, enter the annual STAR+PLUS HCBS program ISP cost limit based on the RUG value and ventilator use of the member (6-23 hours or 24 hours continuous).
  6. Move to the Begin Date field and enter the effective date of the ISP coverage period.
  7. Move to the End Date field and enter the last day of the ISP coverage period.
  8. Move to the Amount Authorized field and enter the total estimated cost of all STAR+PLUS HCBS program services authorized for the current ISP coverage period, from Form H1700-1.
  9. Leave the Amount Paid field at the default setting of 0.00.
  10. Leave the Units Authorized field at the default of 0.00.
  11. Leave the Units Paid field at the default of 0.00.
  12. Select the Save button.

 

 

9140 Service Authorization

Revision 17-1; Effective March 1, 2017

 

If the individual service plan (ISP) is electronic, the Long Term Care (LTC) portal automatically generates service authorization records in the Service Authorization System (SAS). Program Support Unit (PSU) does not register service authorization records for electronic ISPs. PSU confirms service authorization registration in SAS, takes a screenshot, and posts the screenshot to HHS Enterprise Administrative Report and Tracking System (HEART).

PSU staff create one service authorization record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for individuals who do not have an electronic ISP.

To register a service authorization record for initial STAR+PLUS HCBS program eligibility for a member whose ISP is posted to TxMedCentral:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Leave the Fund and Term. Code fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 2 – MONTH from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave the Amount field at the default.
  10. Move to the Begin Date field and enter the effective date of the ISP coverage period.
  11. Move to the End Date field and enter the last day of the ISP coverage period.
  12. Move to the Contract No field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina MMP Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior Medicaid Rural Service Area (RSA) Central 1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup

Medicaid RSA West

1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026332

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.

 

 

9150 Level of Service

Revision 17-1; Effective March 1, 2017

 

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a Resource Utilization Group (RUG) registered on a Level of Service record. This record will be system-generated from information received from Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care Assessment (MN/LOC) and submits the information from this form to TMHP. After TMHP determines MN and computes the RUG value, this information is transmitted and stored in the Service Authorization System (SAS) database

This record is system generated from the information stored in the SAS database. This system-generated record will have an End Date that must be extended through the last day of the month in which the individual service plan (ISP) expires.

Example: If MN/RUG is approved with an effective date of May 13, 2017, the system-generated end date for the Level of Service record will be May 12, 2018. If the ISP period is June 1, 2017 to May 31, 2018, the Level of Service record will need to be extended to May 31, 2018, so the member has coverage for the entire ISP period.

To extend a Level of Service record for a STAR+PLUS HCBS program applicant:

  1. Select the Level of Service area in the Medical Functional area.
  2. Select the check box for the Level of Service record you wish to extend.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If a Level of Service record has not been created in SAS, complete the following steps to add the record:

  1. Select the Level of Service area in the Medical Functional area.
  2. Select Add and a blank Level of Service Details record will appear.
  3. Move to the Type field and select CR – CBA RUG from the drop-down menu.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Level field and enter the RUG.
  6. Move to the Begin Date field and enter the first day of the ISP period.
  7. Move to the End Date field and enter the last day of the ISP period.
  8. Select the Save button.

 

 

9160 Medical Necessity

Revision 17-1; Effective March 1, 2017

 

The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment and submits the information to Texas Medicaid & Healthcare Partnership (TMHP). After MN is determined and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision and it is stored in the Service Authorization System (SAS) database.

This record is system generated from the information stored in the SAS database. This system-generated record will have an End Date that must be extended through the last day of the month in which the MN determination expires.

Example: If MN is approved with an effective date of May 13, 2017, the system-generated end date will be May 12, 2018. If the ISP period is June 1, 2017 to May 31, 2018, the MN record will need to be extended to May 31, 2018, so the member has coverage for the entire ISP period.

To extend an MN record for a STAR+PLUS Home and Community Based Services (HCBS) program applicant:

  1. Select the MN area in the Medical Functional area.
  2. Select the check box for the MN record you wish to extend.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If an MN record has not been created in SAS, complete the following steps to add the record:

  1. Select the MN area in the Medical Functional area.
  2. Select Add and a blank MN Details record will appear.
  3. Move to the MN field and select Y - YES from the drop-down menu.
  4. Move to the Permanent field and select N – NO.
  5. Move to the Begin Date field and enter the first day of the ISP period.
  6. Move to the End Date field and enter the last day of the ISP period.
  7. Select the Save button.

Situations in which the MN record must be forced:

The MN record must be forced in SAS to register an MN determination for these situations:

  • STAR+PLUS HCBS program services are not approved until 120 Calendar days after MN was determined.
  • MN is approved on the portal but will not convert to SAS because of a mismatch of member information between the MN/LOC and TIERS.
  • An applicant who is in a nursing facility and receives Medicaid will begin receiving STAR+PLUS HCBS program services upon discharge from the facility.

To force register MN for a STAR+PLUS HCBS program applicant/member:

  1. Select the MN area in the Medical Functional area.
  2. Select Add and a blank MN Details record will appear.
  3. Move to the MN field and select Y - YES from the drop-down menu.
  4. Move to the Permanent field and select N – NO.
  5. Move to the Begin Date field and enter the first day of the ISP period.
  6. Move to the End Date field and enter the last day of the ISP period.
  7. Move to the Force field and set the Force Flag. Enter Comments explaining why the record is being forced.
  8. Select Force.
  9. Select the Save button.
  10. Select Submit to SAS to submit the authorization.
  11. Select Outbox and then Inbox to ensure the case processed accurately.

 

 

9170 Diagnosis

Revision 17-1; Effective March 1, 2017

 

The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment and submits the information from this form to Texas Medicaid & Healthcare Partnership (TMHP). After TMHP determines MN and computes the RUG value, this information along with the diagnosis code(s) is transmitted to the Texas Health and Human Services Commission (HHSC) and stored in the Service Authorized System (SAS) database.

This record is system generated from the information stored in the SAS database. This system-generated record will have an End Date that is extended through the last day of the month in which the determination expires.

Example: If MN is approved with an effective date of Nov. 13, 2017, the system-generated end date will be Nov. 12, 2018. If the individual service plan (ISP) period is Dec. 1, 2017 to Nov. 30, 2018, the diagnosis record will need to be extended to Nov. 30, 2018, so the member has diagnosis coverage for the entire ISP period.

To extend a diagnosis record for a STAR+PLUS Home and Community Based Services (HCBS) program applicant/member:

  1. Select the Diagnosis area in the Medical Functional area.
  2. Select the check box for the Diagnosis record you wish to extend.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If a diagnosis record has not been created in SAS, complete the following steps to add the record:

  1. Select the Diagnosis area in the Medical Functional area.
  2. Select Add and a blank Diagnosis Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Begin Date field and enter the first day of the ISP period.
  5. Move to the End Date field and enter the last day of the ISP period.
  6. Enter up to five diagnoses.
  7. Leave Version at the default.
  8. Select the Save button.

 

 

9200 Reassessment Service Authorization

Revision 17-1; Effective March 1, 2017

 

When authorizing STAR+PLUS Home and Community Based Services (HCBS) program services for a reassessment of the individual service plan (ISP), check or create the following records according to the instructions for each record:

  • Authorizing Agent
  • Enrollment
  • Service Plan
  • Service Authorization
  • Level of Service
  • Medical Necessity
  • Diagnosis

 

 

9210 Authorizing Agent – Reassessment

Revision 17-1; Effective March 1, 2017

 

Check the record for accuracy. If there are no changes, leave the record open-ended. Currently, although the Service Authorization System (SAS) will accept multiple authorizing agent records, Texas Medicaid & Healthcare Partnership (TMHP) will only accept two authorizing agent records when a SAS file is transmitted to TMHP. Therefore, select NO in the Send to TMHP field for all updates.

 

9220 Enrollment – Reassessment

Revision 17-1; Effective March 1, 2017

 

Check the Enrollment record for accuracy and to be sure it is open-ended. If it is open-ended, make no changes. If it has an End Date, delete the End Date or create another record with a new Begin Date. To ensure that there is not a gap in service, the Begin Date of the enrollment for the new ISP year is the day after the End Date of the previous ISP year.

 

9230 Service Plan – Reassessment

Revision 17-1; Effective March 1, 2017

 

A new Service Plan record must be created to register the Resource Utilization Group (RUG) cost level and the amount of services authorized for the new individual service plan (ISP) year.

Because the ISP is electronic, the Long Term Care (LTC) portal automatically generates service authorization records in the Service Authorization System (SAS). Program Support Unit (PSU) does not register service authorization records for electronic ISPs. PSU confirms service authorization registration in SAS, takes a screenshot, and posts the screenshot to HHS Enterprise Administrative Report and Tracking System (HEART).

 

9240 Service Authorization – Reassessment

Revision 17-1; Effective March 1, 2017

 

If the managed care organization (MCO) posts a timely reassessment packet, Program Support Unit (PSU) staff create one service authorization record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for the new individual service plan (ISP) year. To ensure there is no gap in service, the Begin Date of the authorization for the new ISP year is the day after the End Date of the previous ISP year.

Because the ISP is electronic, the Long Term Care (LTC) portal automatically generates service authorization records in the Service Authorization System (SAS). PSU does not need to register service authorization records for electronic ISPs. PSU confirms service authorization registration in SAS, takes a screenshot, and posts the screenshot to HHS Enterprise Administrative Report and Tracking System (HEART).

If the MCO does not post a timely reassessment packet, two service authorization records will be required for STAR+PLUS HCBS program eligibility. The first service authorization record for STAR+PLUS HCBS program eligibility will be entered with SG 19/SC 13 for the month(s) for which the ISP was late. The second service authorization record for STAR+PLUS HCBS program eligibility will be entered with SG 19/SC 12 for the remaining ISP period.

To enter a service authorization record for an untimely reassessment for STAR+PLUS HCBS program eligibility for a member whose ISP is not electronic:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 13 – NURSING SERVICES  from the drop-down menu.
  5. Leave the Fund and Term. Code fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 4 – PER AUTHORIZATION from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave Amount field at the default.
  10. Move to the Begin Date field and enter the effective date of the new ISP coverage period.
  11. Move to the End Date field and enter the last day of the new ISP coverage period.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina MMP Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior

Medicaid Rural Service Area (RSA) Central

1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup Medicaid RSA West 1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026328

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.

To register a service authorization record for STAR+PLUS HCBS program eligibility for the remainder of the ISP period:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT  from the drop-down menu.
  5. Leave the Fund and Term. Code fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select  4 – PER AUTHORIZATION from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave Amount field at the default.
  10. Move to the Begin Date field and enter the day after the end date of the Service Code 13 record entered above. (This should be the first of the month after the month the late reassessment packet was received.)
  11. Move to the End Date field and enter the last day of the month the packet was received.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include MMP.
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina MMP Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior

Medicaid RSA Central

1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup

Medicaid RSA West

1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026332

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.

 

9250 Level of Service – Reassessment

Revision 17-1; Effective March 1, 2017

 

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a Resource Utilization Group (RUG) value registered on a Level of Service record. This record will be system-generated from information received from Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment and submits the information from this form to TMHP. After TMHP determines MN and computes the RUG value, this information is transmitted and stored in the SAS database.

This record is system-generated from the information stored in the SAS database. This system-generated record will have a Begin and End Date that matches the new individual service plan (ISP) year.

Example: A member with an initial ISP coverage period of Dec. 1, 2017 through Nov. 30, 2018 is re-authorized for STAR+PLUS HCBS program eligibility. The new ISP year will be effective Dec. 1, 2017 through Nov. 30, 2018. These new Begin and End Dates will be system-generated in the Level of Service record.

 

9260 Medical Necessity – Reassessment

Revision 17-1; Effective March 1, 2017

 

The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment for the annual reassessment and submits the information from this form to Texas Medicaid & Healthcare Partnership (TMHP). After MN is determined and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where it is stored in the Service Authorization (SAS) database.

This record is system generated from the information stored in the SAS database. This system-generated record will have a Begin Date and an End Date that matches the newly certified individual service plan (ISP) year.

Example: A member with an initial ISP coverage period of Feb. 1, 2017 through Jan. 31, 2018 is re-authorized for STAR+PLUS Home and Community Based Service (HCBS) program eligibility. The new ISP year will be effective Feb. 1, 2017 through Jan. 31, 2018. These new Begin and End Dates will be system generated in the MN record. The MN record must be forced in SAS to register an MN determination for a reassessment when the MN is approved in the portal but will not convert to SAS because of a mismatch of member information between the MN/LOC Assessment and TIERS.

 

9270 Diagnosis – Reassessment

Revision 17-1; Effective March 1, 2017

 

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a diagnosis registered on a Diagnosis record. This record will be system-generated from information received from Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment and submits the information from this form to TMHP. After TMHP determines MN and computes the Resource Utilization Group (RUG) value, this diagnosis information is transmitted to the Texas Health and Human Services Commission (HHSC) and stored in the Service Authorization System (SAS) database.

This record is system-generated from the information stored in the SAS database. This system-generated record will have a Begin and End Date that matches the new ISP year.

Example: A member with an initial ISP coverage period of Nov. 1, 2017 through Oct. 31, 2018 is re-authorized for STAR+PLUS HCBS program eligibility. The new ISP year will be effective Nov. 1, 2017 through Oct. 31, 2018. These new Begin and End Dates will be system-generated in the Diagnosis record.

 

9300 Transfers

Revision 17-1; Effective March 1, 2017

 

There are several situations that are considered transfers for STAR+PLUS Home and Community Based Service (HCBS) program members, and the procedures differ for each.

 

9310 Transfers from One STAR+PLUS Area to Another STAR+PLUS Area

Revision 17-1; Effective March 1, 2017

 

There are two different situations that can occur when a STAR+PLUS member transfers from one service area to another service area. The first is when a member transfers to a new service area that his current managed care organization (MCO) also serves, and he or she wants to stay with that MCO. Even though he or she is staying with the same MCO, the contract number will change and his records will need to be closed under the previous contract number and opened under the new contract number. The second is when the member changes MCOs in the new service area.

If the member's individual service plan (ISP) is electronic and the member made a new MCO selection timely, the Texas Integrated Eligibility Redesign System updates the Long Term Care (LTC) portal, which automatically closes the registration for the losing MCO and creates the registration for the gaining MCO in the Service Authorization System. If the member's plan change is not timely, the Program Support Unit (PSU) follows existing policy, stated below.

To process the transfer, the losing PSU staff close the existing Authorizing Agent and Service Authorization (SC 12) records. The gaining PSU staff open a new Service Authorization record (SC 12) using the MCO contract number in the new service area.

To close the authorizing agent record:

  1. Open the STAR+PLUS Home and Community Based Services (HCBS) program member’s case in the Service Authorization System (SAS).
  2. Select the Authorizing Agent area from the Case Worker Functional area.
  3. Select the check box for the Authorizing Agent record you wish to close.
  4. Select the Modify button to open and modify.
  5. Move to the End Date field and enter the effective date of the termination, which is the last day of the month in which the member moved to the new service area.
  6. Select the Save button.

To close the authorizing agent record:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select the check box for the appropriate Service Authorization (SC 12) record you wish to close.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and enter the effective date of the termination. This will be the last day of the month in which the member moved to the new service area.
  5. Move to the Termination Code field and select “23 - Transferred to another service” (or the appropriate code) from the drop-down menu.
  6. Select the Save button.
  7. Select Submit to SAS.
  8. Select Outbox and then Inbox to ensure the case processed accurately.

Once the gaining PSU staff verify the month in which the member moves to the new service area, he is responsible for opening the Authorizing Agent and Service Authorization (SC 12) records necessary to authorize the STAR+PLUS HCBS program in the new service area.

The Service Authorization records are opened according to procedures outlined in Initial Service Authorizations for STAR+PLUS HCBS program members with the following exceptions:

  • The Begin Date for these records is the first day of the month following the month the member moved to the new service area.
  • The End Date for the Service Authorization (SC 12) record is the same as the current ISP period.

Example: If a  STAR+PLUS HCBS program member with an ISP period of Nov. 1, 2017 to Oct. 31, 2018 transfers to another STAR+PLUS service area on Jan. 15, 2018, the End Date for these records remains Oct. 31, 2018.

 

9320 Transfers from One Managed Care Organization to Another Managed Care Organization in the Same Service Area

Revision 17-1; Effective March 1, 2017

 

If the member's individual service plan (ISP) is electronic and the member made a new managed care organization (MCO) selection timely, the Texas Integrated Eligibility Redesign System updates the Long Term Care (LTC) portal, which automatically closes the registration for the losing MCO and creates the registration for the gaining MCO in the Service Authorization System (SAS). If the member's plan change is not timely, the Program Support Unit (PSU) follows existing policy, stated below.

The Program Support Unit (PSU) processes the request by closing the existing Service Authorization record (SC 12) for the losing MCO and creating a new Service Authorization record (SC 12) for the gaining MCO.

To close the existing service authorization records:

  1. Move to the Service Authorization area in the Program and Service Functional area.
  2. Select the check box for the appropriate Service Authorization record you wish to close.
  3. Select the Modify button.
  4. Move to the End Date field and enter the effective date of the termination, which is the last day of the month in which the member was enrolled in the losing MCO.
  5. Move to the Termination Code field and select “39 – Other” (or the appropriate code) from the drop-down menu.
  6. Select the Save button.
  7. Select Submit to SAS.
  8. Select Outbox and then Inbox to ensure the case processed accurately.

To create a new service authorization record for the new MCO:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Leave the Fund and Term. Code fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 2 – MONTH from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave the Amount field at the default.
  10. Move to the Begin Date field and enter the new MCO contract number/plan code enrollment date.
  11. Move to the End Date field; the end date for the service authorization record is the last day of the ISP coverage period.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina MMP Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior

Medicaid Rural Service Area (RSA) Central

1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup

Medicaid RSA West

1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026332

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.
  3. Select Submit to SAS.
  4. Select Outbox and then Inbox to ensure the case processed accurately.

 

9400 Follows the Person Authorization for a STAR+PLUS Home and Community Based Services Program Applicant

Revision 17-1; Effective March 1, 2017

 

After the Program Support Unit (PSU) verifies that the individual left the nursing facility, PSU staff complete the following steps listed below. PSU does not close the Authorizing AgentMedical NecessityLevel of Service Resource Utilization Group (RUG) records. PSU must also ensure Provider Claims Services closes the enrollment and service authorization records for Service Codes 1 or 350, and 60.

For individuals who are not enrolled in STAR+PLUS until they begin receiving the STAR+PLUS Home and Community Based Services (HCBS) program, create a one-day service authorization record for the first day of the month in which a Money Follows the Person (MFP) individual is discharged from a nursing facility, unless the individual discharges on the first of a month.

Example: An individual who is not enrolled in STAR+PLUS leaves the nursing facility and begins the STAR+PLUS HCBS program on Dec. 25, 2017. PSU staff register the initial individual service plan (ISP) in the Service Authorization System (SAS) with an effective date of Dec. 25, 2017 through Dec. 31, 2018. In addition to registering the initial ISP, PSU staff create all the records listed below with a Begin Date of Dec. 1, 2018, and an End Date of Dec. 1, 2018.

Add the following records for Service Group 19 to check or create the one-day service authorization:

  • Service Authorization
  • Medical Necessity
  • Diagnosis
  • Level of Service
  • Authorizing Agent (if needed)
  • Enrollment
  • Service Plan

A one day overlap of the records listed is allowed.

Note: Individuals released from a nursing facility and authorized for STAR+PLUS HCBS program services should be enrolled under MFP. In the Enrollment record, select "12 – MONEY FOLLOWS THE PERSON” from the drop-down menu in the Enrolled From field. Do not use “Enrolled from nursing facility” to designate MFP members.

To authorize STAR+PLUS HCBS program eligibility for an MFP applicant:

After creating the one-day records above, when applicable, create the records needed for the ongoing MFP STAR+PLUS HCBS program eligibility. These records must be completed to check or create an initial service authorization for the STAR+PLUS HCBS program:

  • Authorizing Agent
  • Enrollment
  • Service Plan
  • Service Authorization
  • Level of Service
  • Medical Necessity
  • Diagnosis

 

9410 Authorizing Agent for a Money Follows the Person Applicant

Revision 17-1; Effective March 1, 2017

 

There will be one authorizing agent registered for a Money Follows the Person (MFP) applicant.

The Program Support Unit (PSU) or Texas Health and Human Services Commission Enrollment Resolution Services (ERS) staff are registered as the authorizing agent when the initial authorization is authorized.

To register an authorizing agent for an MFP applicant:

  1. Select the Authorizing Agent area in the Case Worker Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Type field and select CM - CASE MANAGER from the drop-down menu.
  4. Move to the Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Leave the Send to TMHP field at the default selection N - NO.
  6. Move to the Begin Date field and enter the date the record is being created. Leave the End Date field blank.
  7. Move to the Authorizing Agent ID field and enter STAR+PLUS.
  8. Leave the Agency field at the default selection 324 - DHS.
  9. Move to the Name field and enter the PSU/ERS staff’s name.
  10. Move to the Phone field and enter the telephone number of the authorizing agent. Enter the area code, phone number and extension.
  11. Move to the Mail Code field and enter the appropriate Managed Care Organization (MCO) Plan Code. Note: Six service areas include Medicare-Medicaid Plans (MMP).
Service Area MCO Plan Name MCO Plan Code

Bexar

Amerigroup

45

Molina

46

Superior

47

Amerigroup MMP 4F
Molina MMP 4G
Superior MMP 4H

Dallas

Molina

9F

Superior

9H

Molina MMP 9J
Superior MMP 9K

El Paso

Molina

33

Amerigroup

34

Molina MMP 3G
Amerigroup MMP 3H

Harris

Amerigroup

7P

United Healthcare

7R

Molina

7S

Amerigroup MMP 7Z
United Healthcare MMP 7Q
Molina MMP 7V

Hidalgo

Cigna-HealthSpring

H7

Molina

H6

Superior

H5

Cigna-HealthSpring MMP H8
Molina MMP H9
Superior MMP HA

Jefferson

Amerigroup

8R

United Healthcare

8S

Molina

8T

Lubbock

Amerigroup

5A

Superior

5B

Medicaid Rural Service Area (RSA) Central Texas Superior C4
United Healthcare C5
Medicaid RSA
Northeast Texas
Cigna-HealthSpring N3
United Healthcare N4
Medicaid RSA
West Texas
Amerigroup W5
Superior W6

Nueces

United Healthcare

85

Superior

86

Tarrant

Amerigroup

69

Cigna-HealthSpring

6C

Amerigroup MMP 6F
Cigna-HealthSpring MMP 6G

Travis

Amerigroup

19

United Healthcare

18

  1. Select the Save button.

 

 

9420 Enrollment for a Money Follows the Person Applicant

Revision 17-1; Effective March 1, 2017

 

To register an authorizing agent for a Money Follows the Person (MFP) applicant:

  1. Select the Enrollment area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Enrolled From field and select the appropriate entry from the drop-down menu. If this is an MFP authorization, be sure to select 12 - MONEY FOLLOWS THE PERSON from the drop-down menu.
  5. Move to the Living Arrangement field, and select the appropriate community-based living arrangement from the drop-down menu.
  6. Move to the Begin Date field and enter the date the member is enrolled in his MCO, which will always be the first day of a month. Leave the End Date field blank.
  7. Leave the Termination Code and Waiver Type at the defaults.
  8. Select the Save button.

 

 

9430 Service Plan for a Money Follows the Person Applicant

Revision 17-1; Effective March 1, 2017

 

The Service Plan record is used to register an individual service plan (ISP) for a STAR+PLUS Home and Community Based Services (HCBS) program member. The record includes the annual STAR+PLUS HCBS program ISP cost limit based on the member’s Resource Utilization Group (RUG) value and the total estimated cost of STAR+PLUS HCBS program services taken from the member’s Form H1700-1, Individual Service Plan.

To register a service plan for a Money Follows the Person (MFP) applicant:

  1. Select the Service Plan area in the Program and Service Functional area.
  2. Select Add and a blank Service Plan Details record will appear.
  3. Leave the Type field at the default selection AN - ANNUAL PLAN.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Ceiling field and enter the annual STAR+PLUS HCBS program ISP cost ceiling for the RUG value entered on the Level of Service record. For a STAR+PLUS HCBS program member who uses a ventilator, enter the annual STAR+PLUS HCBS program ISP cost limit based on the RUG value and ventilator use of the member (6-23 hours or 24 hours continuous).

Move to the Begin Date field and enter the effective date of the ISP coverage period.

  1. Move to the End Date field and enter the last day of the ISP coverage period.
  2. Move to the Amount Authorized field and enter the total estimated cost of all  STAR+PLUS HCBS program services authorized for the current ISP coverage period from Form H1700-1.
  3. Leave the Amount Paid field at the default setting of 0.00.
  4. Leave the Units Authorized field at the default of 0.00.
  5. Leave the Units Paid field at the default of 0.00.
  6. Select the Save button.

 

9440 Service Authorization for a Money Follows the Person Applicant

Revision 17-1; Effective March 1, 2017

 

Program Support Unit (PSU) staff create one service authorization record for  STAR+PLUS HCBS program eligibility.

To register a service authorization record for a Money Follows the Person (MFP) applicant:

  1. Select the Service Authorization area in the Program and Service Functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down list.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Leave the Fund and Term. Code fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 2 – MONTH from the drop down list.
  8. Move to the Units field and enter 1.00.
  9. Leave Amount at the default.
  10. Move to the Begin Date field and enter the effective date of the ISP coverage period.
  11. Move to the End Date field and enter the last day of the ISP coverage period.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina MMP Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior

Medicaid Rural Service Area (RSA) Central

1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup

Medicaid RSA West

1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026332

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.

 

 

9450 Level of Service

Revision 17-1; Effective March 1, 2017

 

There will be an existing Service Group 1 (NF) Level of Service record. However, the Program Support Unit (PSU) will be required to create a new Level of Service record for Service Group 19 STAR+PLUS Home and Community Based Services (HCBS) program. The Service Group 1 (NF) Level of Service record can remain open.

To add a Level of Service record, complete the following steps:

  1. Select the Level of Service area in the Medical Functional area.
  2. Select Add and a blank Level of Service Details record will appear.
  3. Move to the Type field and select CR – CBA RUG from the drop-down menu.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Level field and enter the RUG.
  6. Move to the Begin Date field and enter the first day of the ISP period.
  7. Move to the End Date field and enter the last day of the ISP period.
  8. Select the Save button.

 

 

9460 Medical Necessity for a  Money Follows the Person Applicant

Revision 17-1; Effective March 1, 2017

 

The managed care organization (MCO) nurse completes the Medical Necessity/Level of Care (MN/LOC) Assessment and submits the information to Texas Medicaid & Healthcare Partnership (TMHP) or uses the nursing facility (NF) minimum data set. After MN is determined and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Service Authorization System (SAS) database.

This record is system generated from the information stored in the SAS database. This system-generated record will have an End Date that must be extended through the last day of the month in which the MN determination expires.

Example: If MN is approved with an effective date of May 13, 2017, the system-generated end date will be May 12, 2018. If the ISP period is June 1, 2017 to May 31, 2018, the MN record will need to be extended to May 31, 2018, so the member has coverage for the entire ISP period.

To extend an MN record for an MFP applicant:

  1. Select the MN area in the Medical Functional area.
  2. Select the check box for the existing MN record.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If an MN record has not been created in SAS, complete the following steps to add the record:

  1. Select the MN area in the Medical Functional area.
  2. Select Add and a blank MN Details record will appear.
  3. Leave the MN field at the default of Y - YES.
  4. Leave the Permanent field at the default of N - NO.
  5. Move to the Begin Date field and enter the first day of the ISP period.
  6. Move to the End Date field and enter the last day of the ISP period.
  7. Select the Save button.

Situations in which the MN record must be forced:

The MN record must be forced in SAS to register an MN determination for these situations:

  • STAR+PLUS Home and Community Based Services (HCBS) program services are not approved until 120 calendar days after MN was determined.
  • MN is approved on the portal but will not convert to SAS because of a mismatch of member information between the MN/LOC and TIERS.
  • An applicant who is in an NF and receives Medicaid will begin receiving STAR+PLUS HCBS program services upon discharge from the facility.

To force register MN for an MFP applicant:

  1. Select the MN area in the Medical Functional area.
  2. Select Add and a blank MN Details record will appear.
  3. Leave the MN field at the default of Y - YES.
  4. Leave the Permanent field at the default of N - NO.
  5. Move to the Begin Date field and enter the first day of the ISP period.
  6. Move to the End Date field and enter the last day of the ISP period.
  7. Select the Force button and enter the reason for the force under Force Comments.
  8. Select the Save button.

 

9470 Diagnosis

Revision 17-1; Effective March 1, 2017

 

There will be an existing Service Group 1 Diagnosis record. The Program Support Unit (PSU) must create a new Diagnosis record for Service Group 19 STAR+PLUS Home and Community Based Services (HCBS) program.

To add a Service Group 19 Diagnosis record in the Service Authorization System (SAS), complete the following steps:

  1. Select the Diagnosis area in the Medical Functional area.
  2. Select Add and a blank Diagnosis Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Begin Date field and enter the first day of the ISP period.
  5. Move to the End Date field and enter the last day of the ISP period.
  6. Enter up to five diagnoses.
  7. Leave Version field at the default.
  8. Select the Save button.

 

 

9480 Money Follows the Person Demonstration for a STAR+PLUS Home and Community Based Services Program Applicant

Revision 17-1; Effective March 1, 2017

 

At this time, the option to electronically submit an individual service plan (ISP) for a nursing facility (NF) resident is not available. Managed care organizations (MCOs) must not use the Long Term Care (LTC) portal Money Follows the Person Demonstration (MFPD) check box. The Program Support Unit (PSU) continues to manually register this fund code in the Service Authorization System (SAS).

Follow the instructions for a Money Follows the Person (MFP) applicant above, with the Service Authorization record completed as follows.

  1. Select the Service Authorization area in the Program and Service Functional Area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop down list.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Move to the Fund field and select 19MFP – MONEY FOLLOWS PERSON.
  6. Leave the Term. Code field at the defaults.
  7. Leave the Agency field at the default selection 324 - DHS.
  8. Move to the Unit Type field and select 2 – MONTH from the drop down list.
  9. Move to the Units field and enter 1.00.
  10. Leave the Amount field at the default.
  11. Move to the Begin Date field and enter the effective date of the ISP coverage period.
  12. Move to the End Date field and enter the last day of the ISP coverage period.
  13. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCO Service Area Contract Number

Molina

Bexar

1014430

Molina MMP Bexar 1026341

Molina

Harris

1014431

Molina Harris 1026344

Molina

Jefferson

1019598

Molina

Dallas

1018980

Molina MMP Dallas 1026342

Molina

El Paso

1019987

Molina MMP El Paso 1026343

Molina

Hidalgo

1019988

Molina MMP Hidalgo 1026345

Superior

Bexar

1014433

Superior MMP Bexar 1026337

Superior

Nueces

1014434

Superior

Dallas

1018981

Superior MMP Dallas 1026338

Superior

Hidalgo

1019985

Superior MMP Hidalgo 1026339

Superior

Lubbock

1019986

Superior

Medicaid Rural Service Area (RSA) Central

1025731

Superior

Medicaid RSA West

1025730

United Healthcare

Harris

1014435

United Healthcare MMP Harris 1026334

United Healthcare

Jefferson

1019600

United Healthcare

Medicaid RSA Central

1025732

United Healthcare

Medicaid RSA Northeast

1025734

United Healthcare

Nueces

1014437

United Healthcare

Travis

1014438

Amerigroup

Bexar

1014439

Amerigroup MMP Bexar 1026326

Amerigroup

Harris

1014440

Amerigroup MMP Harris 1026331

Amerigroup

Jefferson

1019599

Amerigroup

Travis

1014442

Amerigroup

El Paso

1019979

Amerigroup MMP El Paso 1026328

Amerigroup

Lubbock

1019983

Amerigroup

Medicaid RSA West

1025729

Amerigroup

Tarrant

1018977

Amerigroup MMP Tarrant 1026332

Cigna-HealthSpring

Tarrant

1018979

Cigna-HealthSpring MMP Tarrant 1026333

Cigna-HealthSpring

Hidalgo

1019984

Cigna-HealthSpring MMP Hidalgo 1026335

Cigna-HealthSpring

Medicaid RSA Northeast

1025733

  1. The NPI field is read-only.
  2. Select the Save button.

Note: Once the 365-day time frame for MFPD has passed, the Fund code in the Service Authorization record will be changed to the default by PSU, when Form H2067-MC, Managed Care Programs Communication, is received from the MCO.

 

9500 Mutually Exclusive Services within the STAR+PLUS Home and Community Based Services Program

Revision 17-1; Effective March 1, 2017

 

To close services that are mutually exclusive, the Texas Health and Human Services Commission (HHSC) case manager must close the non-STAR+PLUS Home and Community Based Services (HCBS) program services with an effective date one day prior to the date the member is eligible for STAR+PLUS HCBS program services.

Example: If an HHSC individual receiving Family Care (FC), Emergency Response Services (ERS) and Home-Delivered Meals (HDM) becomes eligible for STAR+PLUS HCBS program services on Dec. 1, 2017, he will begin receiving his services through his managed care organization (MCO) on that date. Therefore, the losing HHSC case manager must close the FC, ERS and HDM services with an effective date of Nov. 30, 2017.

 

9600 Medically Dependent Children Program/Comprehensive Care Program Transitioning to STAR+PLUS Home and Community Based Services Program

Revision 17-1; Effective March 1, 2017

 

For Medically Dependent Children Program (MDCP)/Comprehensive Care Program (CCP)/Private Duty Nursing (PDN) individuals who are transitioning to the  STAR+PLUS Home and Community Based Services (HCBS) program, the Program Support Unit (PSU) staff will enter the initial STAR+PLUS HCBS program eligibility into the Service Authorization System (SAS) using the steps for initial eligibility with one exception. The effective Begin Date for all records will be the month following individual’s 21st birthday.

It is possible the medical records (Medical Necessity/Level of Care/Diagnosis) will have to be extended to cover the entire individual service plan period.

 

9700 Terminations

Revision 17-1; Effective March 1, 2017

 

If a member's individual service plan (ISP) was created in the Long Term Care (LTC) portal, the Program Support Unit (PSU) will terminate the ISP in the portal. Once this is completed and processed successfully, the service plan and service authorization records automatically close effective on the "to date" of the ISP.

The Enrollment and Service Authorization records must be closed in the Service Authorization System (SAS) when all services for an existing STAR+PLUS Home and Community Based Services (HCBS) program member are terminated. When enrollment is terminated, the authorizing agent has to manually terminate each  STAR+PLUS HCBS program service authorization record.

 

9710 Terminating All Services

Revision 17-1; Effective  March 1, 2017

 

If a member's individual service plan (ISP) was created through the Long Term Care (LTC) portal and is in "processed/complete" or "Program Support Unit (PSU) processed/complete" status, PSU terminates the ISP through the LTC portal if the termination date precedes the ISP "to date"' Once PSU selects the "Terminate ISP" option, the "to date" and "ISP Termination Reason" fields are activated. PSU selects the new "to date" (the termination date) and the termination reason, then clicks "submit to the Service Authorization System (SAS)." The LTC portal ends the SAS service plan and service authorization records effective the amended ISP "to date."

To terminate all services for an existing STAR+PLUS Home and Community Based Services (HCBS) program member whose ISP is not electronic:

  1. Search for the member’s STAR+PLUS HCBS program case and open the file.
  2. Move to Programs and Services Functional area and select Enrollment area.
  3. Select the check box for the existing Enrollment record.
  4. Select the Modify button.
  5. Move to the End Date field and enter the effective date of the termination.
  6. Move to the Termination Code field and select the appropriate code from the drop-down menu.
  7. Select the Save button.
  8. Next, open the Service Authorization (SC 12) records from this area to close any open records.
  9. Select the check box for any open records.
  10. Select the Modify button.
  11. Move to the End Date field of each record and enter the effective date of the termination.
  12. Move to the Termination Code field of each record and select the appropriate code from the drop-down menu.
  13. Select the Save button.
  14. Submit the records.

It is not necessary to close all the existing records for a STAR+PLUS HCBS program service authorization (Medical Necessity/Applied Income, if applicable/Level of Service) unless the member will be transferred to another service group. However, PSU staff can close all these records as well, using the effective date of termination in the End Date fields. If the STAR+PLUS HCBS program member will be transferred to another service group or if he reapplies when these records are still valid, all the existing records for STAR+PLUS HCBS program services must be closed using the effective date of termination in the End Date fields.

 

9800 Appeal Extensions for Continued Benefits

Revision 17-1; Effective March 1, 2017

 

If a STAR+PLUS Home and Community Based Services (HCBS) program member files an appeal and requests continued benefits, Program Support Unit (PSU) staff will extend all records (includes Service Authorization, Service Plan, and Enrollment) by four calendar months. To accomplish this, open each record and modify the record. Change the End Date to the last day of the month – four months in the future (this is completed each time an extension is needed).

Multiple extensions may be requested if the appeal process has not been finalized.